Finalizing your Documentation
The Supreme Court of Canada has affirmed that documentation is a crucial part of patient care. Therefore, the call isn't complete until the electronic Patient Care Record (ePCR) is finalized. Paramedics and Emergency Medical Responders (EMRs) should inform Dispatch when patients are no longer under their direct care (handed over) and when they are completing documentation. Dispatch will provide adequate time for this, depending on the complexity of care given. If you anticipate needing more than 20 minutes, let your channel operator know.
Here's a quick guide to keep in mind:
- Capture Information Promptly: Completing documentation during the patient’s encounter or immediately after handover ensures the most accurate information is captured. This is considered contemporaneous notetaking.
- Timely Finalization: All employees MUST complete and finalize an ePCR for each patient-contact immediately after the encounter (preferred), or at minimum by the end of the scheduled shift, this is mandatory.
- Performance Impact: Leaving an unfinalized ePCR on the dashboard beyond the end of your shift can significantly impact the performance of the Siren application on your Toughbook. All documentation must be thoroughly completed and finalized before the end of each shift.
- Acceptable Deferrals: Documentation is a part of patient care; short deferrals of contemporaneous documentation is only acceptable when it compromises patient care or crew safety and only considered in the following examples:
- Dispatch requests you to attend a high priority call or significant event, and no other units are available in a reasonable time frame to attend.
- It is unsafe to complete your documentation at your current location, and you must relocate.
- In rare and extenuating circumstances deferral of documentation past the end of your shift is required, this must be approved by a supervisor or manager, with an occurrence report and explanation in the narrative.